Part 5 – Covered Services (continued) IMPORTANT: Refer to the Schedule of Benefits for your plan option for the cost share amounts that you must pay for covered services and for the benefit limits that may apply to specific covered services. Once you reach your benefit limit for a specific covered service, no more benefits are provided by Blue Cross Blue Shield HMO Blue for those services or supplies. WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 54  Pain management services furnished for you by a covered provider. These covered providers can furnish services such as: nerve block injections or epidural steroid injections (these injections are covered as a surgical service, see “Surgery as an Outpatient”); and electro-muscular stimulation and spinal cord and dorsal root stimulation (see “Medical Care Outpatient Visits” for your coverage for outpatient care to diagnose or treat your medical condition).  Occupational therapy and/or physical therapy (see “Short-Term Rehabilitation Therapy”). Alternative treatments to opiates for pain management also include non-opiate covered drugs and supplies that are furnished by a covered pharmacy when your prescription drug coverage is provided under this health plan. Your coverage for these covered services is provided to the same extent as coverage is provided for similar covered services to diagnose and treat a physical condition. (A benefit limit may apply for a specific covered service listed above. If this is the case, the benefit limit will be described in the Schedule of Benefits for your plan option and/or any riders that apply to your coverage in this health plan.) PANS/PANDAS Treatment This health plan covers services to treat pediatric autoimmune neuropsychiatric disorders (PANS) associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome (PANDAS) including, but not limited to the use of intravenous immunoglobulin therapy when they are furnished by a covered provider. Your coverage for these covered services is provided to the same extent as coverage is provided for similar covered services to treat other physical conditions. Podiatry Care This health plan covers non-routine podiatry (foot) care when it is furnished for you by a covered provider. This may include (but is not limited to): a physician; or a podiatrist. This coverage includes: diagnostic lab tests; diagnostic x-rays; surgery and necessary postoperative care; and other medically necessary foot care such as treatment for hammertoe and osteoarthritis. No benefits are provided for: routine foot care services such as trimming of corns, trimming of nails, and other hygienic care, except when the care is medically necessary because you have systemic circulatory disease (such as diabetes); and certain non-routine foot care services and supplies such as foot orthotics, arch supports, shoe (foot) inserts, orthopedic and corrective shoes that are not part of a leg brace (except as described in this Subscriber Certificate for “Prosthetic Devices”), and fittings, castings, and other services related to devices for the feet. Prescription Drugs and Supplies This health plan covers certain drugs and supplies that are furnished by a covered pharmacy. This coverage is provided only when all of the following criteria are met.  The drug or supply is listed on the Blue Cross Blue Shield HMO Blue Drug Formulary as a covered drug or supply. For certain covered drugs, you must have prior approval from Blue Cross Blue Shield